Electrical System Deficiencies in Resident Rooms
Summary
The facility failed to maintain electrical systems in wet locations, as evidenced by a damaged Ground Fault Circuit Interrupter (GFCI) receptacle next to the sink in resident room 142. This deficiency was observed during a survey conducted on December 30, 2024, between 10:45 a.m. and 12:00 p.m. Additionally, in resident room 112, an electrical receptacle was found pulling out of the electrical box behind the TV stand, and a blank receptacle cover was missing at the bottom right of the P-Tec, close to the floor. These issues were confirmed during an interview with the Executive Director at the exit conference on the same day.
Plan Of Correction
The ground fault circuit interrupter (GFCI) receptacle in room 142 was replaced on 01/13/2025. The Facility Director or appointee will inspect, test, and audit all GFCI receptacles at time of repair and then quarterly thereafter.
Penalty
Surveyors identified that three electrical receptacles in the facility were not GFCI protected as required, including those near a sink in the café, a water fountain near the nurse station, and a juice machine in the kitchen. These deficiencies were confirmed by the maintenance supervisor.
A kitchen electrical receptacle near the hand sink was found without required GFCI protection during an observation, and this deficiency was confirmed by the administrator and maintenance supervisor.
Surveyors found that an electrical outlet near a waterline was not GFI-protected, a damaged outlet faceplate was present in a resident room, and GFI outlets were not tested according to manufacturer instructions. Staff were unaware of these issues, and the deficiencies affected multiple residents and smoke compartments.
The facility was found non-compliant with GFI protection requirements for power receptacles within six feet of a water source in three smoke zones. Observations revealed non-GFI protected outlets in the D Hall Nurses' Station Nourishment Area, B Hall Beauty Shop, and Main Kitchen Prep Area. This was confirmed by the Assistant DON and Maintenance Director.
The facility failed to maintain electrical receptacles in compliance with safety standards in one of over thirty rooms. An observation revealed that the A wing resident laundry room had a washing machine without GFCI protection. This deficiency was confirmed by the maintenance supervisor.
The facility did not ensure that power receptacles were GFI protected within six feet of a water source in one of the smoke zones. Observations revealed non-GFI protected outlets behind an ice machine near a resident room and in the Boiler/Generator Room. This was confirmed by the Administrator and Maintenance Director.
Failure to Maintain GFCI Protection for Electrical Receptacles
Penalty
Summary
Surveyors observed that the facility failed to maintain electrical receptacles in accordance with NFPA 101 and NFPA 99 standards. Specifically, three deficiencies were identified: a receptacle in the main floor Sweet Shop café was not GFCI protected within six feet of a sink basin; a water fountain near the main floor center core nurse station was not connected to a GFCI protected receptacle; and a juice machine in the main floor kitchen was not connected to a GFCI protected receptacle. These deficiencies were confirmed during an interview with the maintenance supervisor. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Education was provided to the Maintenance department by the Nursing Home Administrator regarding the requirement of having power receptacles to have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. All identified outlets were changed over to GFCI outlets on day of survey. A whole house observation of all outlets near water sources was inspected with no others identified. Ongoing compliance will be maintained through daily rounding by the Environmental Service Supervisor or designee 3x weekly for 2 weeks. K 0912
Lack of GFCI Protection on Kitchen Electrical Receptacle
Penalty
Summary
During an observation conducted on July 30, 2025, at 11:36 a.m., it was found that an electrical receptacle located in the kitchen near the hand sink did not have ground fault circuit interrupter (GFCI) protection as required. This deficiency was confirmed through interviews with both the administrator and the maintenance supervisor at the same time. The report specifically notes that this issue was present in one of over twenty rooms observed. No additional details regarding patient involvement, medical history, or the condition of any residents at the time of the deficiency are provided in the report.
Plan Of Correction
Education will be provided to maintenance. All outlets within 6 feet of a water source are GFCI. The outlet by the hand sink was replaced to be GFCI on 7/30/25. The dietary manager or designee will audit the outlet by the hand sink to ensure it is GFCI weekly for 4 weeks. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
Deficiencies in Electrical Outlet Safety and Maintenance
Penalty
Summary
Surveyors identified several deficiencies related to electrical outlets during a facility tour, document review, and staff interviews. In the auxiliary space between two resident rooms, an electrical outlet located beneath a waterline and connected to a refrigerator was found to lack Ground Fault Interrupter (GFI) protection. The Environmental Consultant was unaware of this issue and stated it had not been noted in previous life safety surveys. Additionally, in a resident room, a damaged and bent electrical outlet faceplate was observed, which was not flush with the outlet. The Maintenance Consultant was also unaware of this damage. Further review of documentation revealed that GFI outlets were being tested only annually, despite the manufacturer's instructions on the outlet cover indicating that testing should occur monthly. The Maintenance Consultant confirmed that all outlets were tested annually and was not aware of the monthly testing requirement. These deficiencies affected three of five residents and one of two smoke compartments, as noted in the findings.
Plan Of Correction
The outlet in the Snack Shack was replaced with a GFI receptacle. The wall plate in the resident room was replaced that afternoon. (See attached photos.) The Director of Maintenance will audit the electrical receptacles throughout the building monthly and ongoing, to ensure that each receptacle is in proper working order. The Administrator will review the audits quarterly and bring findings to the Quality Assurance Team as part of the QAPI safety program evaluating the effectiveness. This corrective action was completed June 20th, 2025.
Non-Compliance with GFI Protection Near Water Sources
Penalty
Summary
The facility failed to maintain power receptacles with Ground Fault Interruption (GFI) protection within six feet of a water source in three of six smoke zones. During an observation on April 16, 2025, between 12:30 PM and 12:45 PM, it was noted that various outlets were not GFI protected. Specifically, at 12:30 PM, one outlet in the D Hall Nurses' Station Nourishment Area was found to be non-compliant. At 12:40 PM, three outlets in the B Hall Beauty Shop, located by sinks, were also not GFI protected. Additionally, at 12:45 PM, two outlets in the Main Kitchen Prep Area, near the coffee machine and ice machine, were identified as lacking GFI protection. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the time of the exit conference on the same day.
Plan Of Correction
1 and 2. Maintenance Director has updated GFI's in D hall nurses station nourishment room (1 outlet), B hall beauty shop (3 outlets), and main kitchen prep area (2 outlets). 3. Maintenance department will be educated on the standards of maintaining power receptacles to be GFI within six feet of a water source. 4. Maintenance or facility designee will audit facilities GFI receptacles weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Electrical Receptacle Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with safety standards in one of over thirty rooms. During an observation on April 8, 2025, at 10:55 a.m., it was noted that the A wing resident laundry room had a washing machine that was not equipped with ground fault circuit interrupter (GFCI) protection. This deficiency was confirmed through an interview with the maintenance supervisor at the same time, who acknowledged the lack of GFCI protection for the electrical outlet in question.
Plan Of Correction
Laundry room receptacle replaced with ground fault circuit interrupter protection. Whole house audit to be completed by Environmental Services Supervisor or designee to ensure all outlets are in compliance by 4/30. Findings to be discussed at Quality Assurance Performance Improvement meeting.
Failure to Maintain GFI Protection Near Water Sources
Penalty
Summary
The facility failed to maintain power receptacles with Ground Fault Interruption (GFI) protection within six feet of a water source in one of the eight smoke zones. During an observation conducted on March 13, 2025, between 11:42 AM and 12:10 PM, it was noted that outlets were not GFI protected in specific locations. These locations included the 2nd floor behind the ice machine by Resident Room F5 and in the Boiler/Generator Room by the boiler lines on the exterior wall, where three outlets were identified. This deficiency was confirmed during an interview with the Administrator and Maintenance Director at the time of the exit conference on the same day.
Plan Of Correction
The outlet on the 2nd floor, behind the ice machine, by Resident Room F5 was replaced with a GFI protected outlet. The 3 outlets in the Boiler/Generator Room, by the boiler lines exterior wall were replaced with GFI protected outlets. The Maintenance Director was re-educated on the need for GFI protected outlets within six feet of a water source. A facility wide inspection for GFI outlets will be conducted and whenever an outlet is replaced to ensure GFI protection within six feet of a water source.
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